Which statement best describes the acute management of hyperkalemia in a patient with CKD presenting with ECG changes?

• A. IV calcium to stabilize the myocardium, then shift K+ into cells (insulin with glucose or albuterol) and remove K+ (diuretics, dialysis, or potassium binders).
• B. IV bicarbonate to correct acidosis only.
• C. Hemodialysis first, then potassium binders.
• D. Give potassium supplements.

Answer: (A)

In acute hyperkalemia with ECG changes, the priority is to prevent dangerous arrhythmias and rapidly reduce potassium. The best approach has three steps in order: first stabilize the heart with IV calcium, which protects the myocardium regardless of how high the potassium is. Then shift potassium into cells to lower the serum level quickly, using insulin with glucose and a beta-agonist such as albuterol. Finally remove potassium from the body through methods like diuretics, dialysis, or potassium-binding agents, with dialysis often needed in CKD due to limited renal excretion.

Calcium doesn’t lower potassium by itself, but it buys time and stabilizes cardiac membranes so it’s given immediately when ECG changes are present. After stabilization, shifting potassium into cells reduces serum level rapidly, and removal addresses the ongoing excess. IV bicarbonate can help if acidosis is present, but it’s not a stand-alone treatment when acute ECG changes are already occurring. Dialysis or binders alone don’t address the immediate threat to the heart, and giving potassium would worsen the situation.